Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident’s comprehensive care plan was revised in a timely manner to reflect current fall interventions after a fall event. The resident was admitted with diagnoses including acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia. A care plan dated 03/10/26 identified the resident as being at risk for fall-related injury and falls due to history and fear of falling, with a goal to remain free from injury related to falls. A nursing note dated 03/25/26 documented that the resident went to the hospital, without additional information. In an interview, the resident reported having a fall that required hospital transfer, though he did not specify the date. Further review of the care plan showed that specific fall interventions, including reorienting the resident at bedside and providing a visual cue to use the call light for assistance, were created on 04/09/26 and were related to the fall that occurred on 03/25/26. In an interview, the DON confirmed that these interventions, which were implemented immediately after the fall, were not added to the written care plan until 04/09/26, leaving the care plan not up to date until that date. The facility’s “Care Planning” policy required that every resident have a person-centered care plan developed and implemented based on the comprehensive assessment, with measurable objectives and time frames to meet identified needs, but the resident’s care plan was not revised promptly after the fall as required.

Plan Of Correction

1. Resident #86 had their fall care plan updated on 4/9/26 by the Director of Nursing to reflect current fall interventions. 2. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC an audit of falls for the past 30 days will be completed by the Director of Nursing or designee to ensure fall care plans reflect current fall interventions. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Fall Management Policy to include updating the care plan with new interventions as appropriate. This education will be completed on or before 5/13/26. 4. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will audit new admissions, readmissions and residents who experience a fall weekly for four weeks, beginning 5/14/26 to ensure fall care plans reflect current fall interventions. Discrepancies noted during audits will be corrected with care plans updated to reflect current fall interventions. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.

Plan Of Correction

THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that comprehensive care plans were prepared, reviewed, and revised by an interdisciplinary team and that care conferences were scheduled and conducted quarterly, as required by facility policy. For one resident with cerebral atherosclerosis, stage IV kidney disease, and hypertension, records showed multiple timely MDS assessments and a care plan addressing risk for skin breakdown, but only one documented interdisciplinary care conference over an extended period. No additional care conferences were recorded in the electronic health record despite ongoing quarterly and annual assessments. Another resident with atrial fibrillation, COPD, chronic pain, and nutritional risk had an admission assessment and several quarterly MDS assessments completed, along with a care plan addressing nutritional risk and monitoring needs. However, the electronic record showed only one documented care conference, and both the resident and family confirmed they had not participated in quarterly care conferences. A third resident with Alzheimer’s disease, dementia, and psychotic disturbance had multiple quarterly and annual MDS assessments and a care plan for psychotropic medication monitoring, but only four care conferences were documented over a broad time frame, with all marked in error status. One of these assessments was incomplete, with only restorative nursing and nursing sections signed, and the resident’s family confirmed that quarterly care conferences had not occurred. A fourth resident with acute and chronic heart failure and vascular dementia with behaviors had multiple quarterly and annual MDS assessments completed and required staff assistance with ADLs. The electronic record showed only two care conferences, both noted as in error status or in progress, and one was incomplete with only restorative nursing and nursing sections signed. A corporate RN verified that the care conference assessments in the system were in error status, meaning the conferences were not complete and/or lacked required information and signatures, and confirmed that quarterly care conferences for all four residents had not been conducted as required. Review of the facility’s Resident Assessment policy showed that residents were to have the opportunity to discuss their goals of care and that care plans were to be developed by an interdisciplinary team with resident and/or family participation, but this policy was not implemented as written.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to revise a resident’s care plan in response to repeated resident-to-resident incidents and newly implemented staff interventions. Resident #7 was admitted on 11/15/22 with diagnoses including COPD, major depressive disorder, chronic viral hepatitis, mild dementia, and type 2 diabetes. Resident #13, admitted on 01/30/24 with cerebral palsy, osteogenesis imperfecta, type 2 diabetes, major depressive disorder, need for assistance with personal care, convulsions, and aortic stenosis, was involved in two separate incidents with Resident #7 in Resident #13’s room. A nursing note dated 09/27/25 documented that Resident #7 was found in Resident #13’s room, after which staff verbally instructed Resident #7 not to enter Resident #13’s room and demonstrated an alternate route to the back of the facility for smoking and activities so he could avoid passing by Resident #13’s room. A self-reported incident dated 12/07/25 showed a second incident in which Resident #7 was again found in Resident #13’s room and was reminded by staff that he could not be there and needed to leave. Review of Resident #7’s care plan, with a review date of 12/23/25, showed an identified problem of alteration in cognitive function secondary to dementia, with interventions such as assisting with decision making, monitoring for changes in condition and cognition, and offering verbal reminders and cues. However, the care plan contained no revisions to reflect the two resident-to-resident incidents on 09/27/25 and 12/07/25, nor did it include the specific interventions directing Resident #7 not to enter Resident #13’s room or to use the alternate route to the back of the facility. A quarterly MDS 3.0 assessment for Resident #7 indicated he was cognitively intact, did not exhibit behavior symptoms or rejection of care, was independent with transfers, could self-propel in his wheelchair, and required setup to moderate assistance for ADLs. In an interview, the DON confirmed there were two incidents between the residents in Resident #13’s room, that Resident #7 had been educated about not entering that room and about using an alternative route, and that these interventions were not added to Resident #7’s care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to conduct and document initial and quarterly care plan conferences with residents and/or their representatives as required by regulation and facility policy. The facility policy states that patient care conferences are to be held within seven days of admission, upon significant change, and quarterly thereafter, with the interdisciplinary team developing a comprehensive, person-centered care plan in conjunction with the resident and family or legal representative. For multiple residents, surveyors found missing or significantly delayed care conferences despite completed MDS assessments and intact cognition, and the Social Service Director confirmed that required conferences were not held. For one resident with diagnoses including moderate protein malnutrition, cystic fibrosis, ALS, anxiety, gastrostomy, chronic pain syndrome, major depression, and functional quadriplegia, records showed care conferences only on 02/10/25 and 10/15/25, with no evidence of quarterly conferences in between. Another resident with diabetes, morbid obesity, adult failure to thrive, COPD, chronic respiratory failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder, and PTSD had intact cognition and required varying levels of ADL assistance, yet there was no documented evidence of any plan of care conferences. The Social Service Director verified that quarterly care conferences were not held for these residents. Additional residents were similarly affected. One resident with protein calorie malnutrition, COPD, peripheral vascular disease, and atherosclerosis with leg ulceration had care conferences documented only on 02/05/25 and 04/11/25, with no further quarterly meetings. Another resident with type 2 diabetes, a right below-knee amputation, moderate protein-calorie malnutrition, and chronic kidney disease had intact cognition, but there was no evidence of any care conferences; the resident reported never attending a care conference, and the Social Service Director stated conferences were not done due to the resident’s inappropriate sexual behaviors and inability to reach family, without documentation of attempts or explanations as required by policy. One resident admitted with acute on chronic diastolic heart failure, ulcer of anus and rectum, and type 2 diabetes had an admission care conference, during which the resident requested that the wife not be notified; however, no quarterly care conferences were completed afterward, despite an MDS showing intact cognition. The resident stated they were not aware of any care conferences being held. Another resident with malignant carcinoid tumor of the stomach, severe protein-calorie malnutrition, type 2 diabetes, and vascular dementia, with severe cognitive impairment and a son listed as emergency contact, had no evidence of an initial care conference with either the resident or responsible party. The Social Service Director confirmed there was no initial care conference and could not explain why. A further resident with acute and chronic respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation had intact cognition and required assistance with ADLs, with documentation that the resident rejected care on some days. The medical record contained no indication that a care conference had been conducted or attempted. The resident reported not being asked to participate in care plan meetings, expressed a desire to go home, and stated dislike of social work interactions, indicating no opportunity to engage in the care planning process. The Social Work Director confirmed there was no documentation of a care conference, acknowledged only a verbal discussion about a potential conference months earlier, and no subsequent attempts or documentation, contrary to the facility’s comprehensive person-centered care plan policy requiring conferences and documentation of refusals or impracticability.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to conduct admission and quarterly care conferences in a timely manner and in accordance with its own policy and regulatory requirements. For one resident with cerebral infarction, hemiplegia/hemiparesis, and need for assistance with personal care, the record showed the last care conference occurred on 03/28/25, with no subsequent conferences documented; the Social Services Director confirmed no care conferences had been held since 03/08/25. Another resident with end stage renal disease, polyneuropathy, and an above-knee amputation had no documented care conferences at all since admission, and there was no record of discharge planning discussions; this resident reported being upset about not having a care conference and being uninformed about discharge planning, and the Social Services Director confirmed the absence of any care conferences or proof of discharge planning discussions. A resident with cognitive communication deficit, traumatic brain injury, and need for assistance with personal care had only one care conference documented on 10/22/25, with no care conference held within 72 hours of the admission date of 09/01/25, as confirmed by the Social Services Director. Another resident, cognitively intact and admitted with pleural effusion, end stage renal disease, chronic respiratory failure, heart failure, and malignant neoplasm, had a documented 72-hour admission conference on 12/02/25 with the responsible party, social services, and MDS nurse present, and an identified plan to discharge to the community. A further resident with a complete lesion of the thoracic spinal cord, paraplegia, urologic complications, and neuromuscular bladder dysfunction had care conferences on 09/24/24, 11/25/24, and 02/27/25, but no quarterly care conferences after 02/27/25, which the Social Services Director confirmed. Review of the facility’s “Care Planning Conference” policy dated 03/03/25 showed that interdisciplinary care conferences are to be held on admission, annually, quarterly, with significant change, at discharge as needed, and as needed, to identify problems, needs, goals, and discharge plans, which was not consistently followed for these residents.